Standard Tracheal Intubation
Provided early detection of hematoma formation and clinical assurance of upper airway patency, standard tracheal intubation may be successfully performed after intravenous induction of general anesthesia and muscle relaxation using conventional laryngoscopy (CL). We emphasize that conventional tracheal intubation should be limited to a maximum of two attempts (23); reliance on repeat attempts at CL is a risk-enhancing behavior that frequently leads to the development of progressive difficulties with face-mask ventilation and identification of laryngeal structures (17).
Optimal preparation for CL and tracheal intubation with proper patient positioning and external laryngeal manipulation should be already provided during the first attempt. Poor laryngeal views at this early state of airway management, indicating predictive of a difficult conventional tracheal intubation even for an experienced operator, should give rise to initiate rational decisions: selecting an alternative technique including flexible-bronchoscopy assisted (FBA) tracheal intubation and tracheal intubation using an optical or a video laryngoscope, or proceeding with insertion of a laryngeal mask airway with the option of using this device as conduit for tracheal intubation, preferably under guidance of a flexible bronchoscope (FB).
We consider the Airtraq optical laryngoscope, the various models and systems of the GlideScope video laryngoscope, and other type video laryngoscopes as valuable supplements to the FB. These laryngoscopes are easy to use, provide image magnification, and the obscured view by soft tissues frequently seen during FBA intubation is usually controlled by the operator due to the blade designs. As special feature, the optical and video camera systems are resistant to fogging. In patients with difficult conventional laryngoscopy, they usually provide a superior exposure of laryngeal structures but this does not guarantee successful tracheal intubation (22, 24). For freehand guidance of the tracheal tube through the laryngeal aperture into the trachea, the Schroeder directional tracheal tube stylet should be considered.
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